【作者】 郑林娟；

【导师】 傅永军；

【作者基本信息】 山东大学 ， 外国哲学， 2012， 博士

【摘要】 这篇论文致力研究美国著名生命伦理学家恩格尔哈特的思想,重点讨论恩格尔哈特俗世生命伦理学的核心问题——“允许原则”。这篇论文写作的理论意义在于详尽解读恩格尔哈特“允许原则”产生的历史文化语境、医生权威和患者自主的博弈、允许原则的内涵及意义和局限性、允许原则对于中国可能产生的效用,进一步拓深、推进国内学术界对恩格尔哈特“允许原则”的研究。这篇论文写作的实践意义在于借鉴“允许原则”来重新审视中国医疗实践中“知情同意”的现状、存在的问题,并对价值多元化境遇下的医患冲突或分歧提供伦理上的指导和建议,以期改变我国医疗技术水平与世界接轨而生命伦理学理论建设相对薄弱的现状。在研究方法上,这篇论文主要使用了文献研究法和案例分析法。上个世纪五六十年代,伴随着医学高新技术的发展,美国的传统宗教信仰受到世俗主义的挑战、医生的权威受到质疑(二战后,美国发生了欺骗或诱导受试者的非人道的人体试验)、病人权利运动的兴起以及美国多元文化信仰的共生等促成了人们对生命伦理问题的关注和争论。针对生命伦理学领域中的众多分歧和争议,很多生命伦理学家试图构建具有实质内容的生命伦理学共识。与主流研究方式不同,美国著名生命伦理学学者恩格尔哈特教授另辟蹊径,针对生命伦理学领域中诸问题的多元化语境,提出了程序性的生命伦理学共识——“允许原则”,并做出了具有较强适用性的解决医患双方道德分歧的论证,在国际生命伦理学界引起了巨大反响。为了阐述恩格尔哈特构建“允许原则”的合理性,作者首先详细考察了恩格尔哈特思想所处身其中的历史-理论语境,即：后现代状况与道德多元化、理性的有限性和古典自由主义的影响。受这些历史-理论语境的影响,恩格尔哈特生命伦理学具有明显的后现代特征。他本人承认其主要著作《生命伦理学基础》就是一部后现代的著作。从后现代出发,恩格尔哈特认为道德多元化在美国是不可避免的。在他看来,由于不同的道德共同体存在不同的道德前提和预设,所以道德异乡人之间的争论无休无止,而恩格尔哈特程序性原则的一个重要起点,恰恰在于对这种差异性的关注。与启蒙运动道德工程坚持构建一个客观的、普遍有效的道德观以解决道德分歧不同,恩格尔哈特则认为启蒙运动的道德工程在跨文化的背景下是不可能实现,客观的、普遍有效的道德观仅存在于具体的道德共同体中。在他看来：“所有的人类道德都关注自由、平等、繁荣和安全,这也许将成为一个事实,但是按照如何去判断以及结合这些关系,一种明显不同的道德规范就得以建立。”由此可见,恩格尔哈特不仅受到麦金泰尔的影响,而且也深受后现代主义者影响,力行后现代多元性、异质性和平等性之主张,相信理性无法证明某一种道德观为最优。基于这种识见,恩格尔哈特主张,道德分歧的解决只能求助于参加争论的人,人成为道德权威的来源。据此推出,恩格尔哈特还是一个有着古典自由主义思想情结的生命伦理学家,尽管他本人并不同意这种分析。恩格尔哈特本人认为,他从未主张个人选择具有最重要的价值,只是由于我们无法继续得到上帝的恩典而且启蒙运动的道德工程已经坍塌,我们才不得不求助人来作为道德的权威。在他看来,自由只是生命伦理学的一个先验条件。既然客观的、普遍有效的道德共识无法形成,那么程序性的共识就可能是解决道德分歧的路径。对恩格尔哈特思想产生语境的解读,以及通过解读对其思想倾向的分析,为作者理解恩格尔哈特关于医生权威和病人自主之间的博弈的思想提供了诠释基础。恩格尔哈特认可在某些情况下医生可以行使家长主义的权威,如针对“没有行为能力的个体”(包括两种类型：一类是那些从未有过行为能力的个体,诸如婴儿、幼儿、先天的严重智力障碍者；另一类是那些一度有行为能力但在丧失行为能力之前未能提前提示应该如何治疗他们的人,如尚未“预立遗嘱”而成为植物人或昏迷的成年人)、有行为能力但明确或暗示将治疗的决策权委托给医生的患者。现在的问题是,当医生和一个有行为能力的患者发生道德分歧时,应该怎么办?他提供了四种解决的路径：强制、分歧的双方中有一方转变了自己的立场、圆满的理性论证和同意(又称为允许、人所不欲勿施于人)。针对第一种路径,恩格尔哈特指出,由于许多人注意到知识具有以历史和文化为条件的特征,对于医学知识的任何描述都会受到不同科学家共同体所属历史和文化的影响,所以我们无法给出一种中立的、纯描述的疾病说明。就此而言,即使医生能够提出他所认为的好的、对的医学决策,患者本人也未必就认同这种医学决策。强制是不可行的,它是一种典型的伦理帝国主义,是一种不讲道理的压服方式。解决医患冲突的第二种路径,情况有点复杂,因为现实中并不排除由于分歧的一方放弃自己的立场而使得医患冲突得以化解。但是,不可否认的是,希望所有的道德争端都通过这种方式解决是不现实的,‘因为历史和现实一再证明各大文化传统并没有整合为一个文化传统。正如恩格尔哈特在《生命伦理学基础》的导言中所言：20世纪一些专制的政治领袖试图用强制手段使国家成为单一的道德共同体,但尽管经过了野蛮的镇压,多样性依然如故。所以说,强制都不能实现的事情,完全依靠个人的自觉,从一个道德共同体转入另一个道德共同体只能是偶尔的现象,不具有普遍性。第三种路径即借助圆满的理性论证解决医患冲突,在启蒙道德工程失去合法性之后,它的不可能性已经是不争的事实。如此看来,唯有第四种路径可行。也就是说,“同意(允许)”是我们解决道德分歧的最好方式。在恩格尔哈特看来,允许原则的实现至少需要满足三个条件：允许原则的参与者是具备自我意识、理性、道德感和自由的“人”：人应该属于某种道德共同体;“自由的和知情的同意”是允许原则实现的核心。基于上述分析,作者进一步比较了允许原则和行善原则、允许原则和正义原则,通过论证确立了允许原则的优先性。这在一定程度上克服了生命伦理“四原则说”(有利或行善、无伤、尊重自主和公正)的局限性。恩格尔哈特的“允许原则”在生命伦理学领域引起了众多争议。本文作者认为“允许原则”的主要价值和意义在于：第一,恩格尔哈特能够超越自身东正教的立场,站在各个共同体之上看待人们之间的争议,并构建了一个中立性的道德框架——相互尊重、平等协商。他确立了针对道德异乡人的正确的道德箴言：人所不欲,勿施于人。这有利于全球范围内道德异乡人之间的和平合作。第二,恩格尔哈特反对将西方的价值观作为普适的伦理观,而且他充分尊重各个国家和民族的文化传统。在他看来,全球伦理在西方是一种很强势的观念,有一些欧洲人受到启蒙主义的影响,总认为他们是唯一正确的。恩格尔哈特正好与他们反其道而行之。他认为可以通过对话、交流、劝说来影响道德异乡人的道德观,同时每个人都应宽容道德异乡人的审慎的、理性的决定。第三,恩格尔哈特对允许原则的强调,让我们看到多数派的民主决策机制的局限性。在仅涉及个人重大利益而没有对他人造成伤害或仅有细小伤害时,个人对自己的生命应该拥有决定权。当然,“允许原则”不是一个圆满无暇的原则,它不可能解决所有的生命伦理问题。这样看并不会抹杀“允许原则”所应具有的价值。作者认为,针对道德异乡人的道德分歧而言,恩格尔哈特给出了一个非常圆满的论证,即确立了医生家长主义和国家卫生保健政策之权威的限度。具有古典自由主义倾向的“允许原则”对中国会产生哪些影响呢?作者相信,无论我们把现代中国社会主要看作是一个权力高度集聚的大一统社会,还是看作正在走向价值多样的世俗化社会,允许原则对我们都有借鉴意义。首先,中国对外交流日益频繁,医疗领域的合作不可避免会面对道德异乡人的困境,这种境况完全可以参照“允许原则”来解决可能面对的道德分歧。其次,我国自1985年进行卫生体制改革以来,由于优质医疗资源的紧张、医疗费用的上涨以及市场机制引入医疗机构等原因,医患冲突时有发生,医患关系呈现紧张的趋势,迫切需要构建和谐的医患关系。在这种大背景下,医疗高新技术的研究和临床应用稍有不慎,即刻触动医患之间敏感的神经,所以我们在开展器官移植、辅助生殖、人体试验等方面,应借鉴尊重、充分告知、沟通、理解等手段,增进医患之间的平等交往,重建医患之间的信任。更多还原

【Abstract】 This dissertation aims to study the thoughts of Engelhardt, a renowned American Bioethicist, focusing on the key issue of his secular bioethics, the Principle of Permission. This dissertation will elaborate on the historical and cultural contexts of Engelhardt’s Principle of Permission, tension of doctors’ authority and patients’ independent rights, the meaning, significance, and limitation of this Principle, and the possible application of this Principle in China. Such research is the first of its kind in the systematic research of Principle of Permission. The practical significance of this dissertation is to re-examine the current conditions and problems of informed consent in China in light of Principle of Permission and to give ethical guidance and suggestions to doctor-patient conflicts or disagreements in the pluralistic value context, in order to bring changes to the current situation, where Chinese medical techniques are conformed to the world while our bioethics are comparably weak. In terms of methodology, this dissertation uses literature research method and case-study method.In the1950s and1960s, with the development of advanced medical techniques, American traditional religious beliefs were challenged by secularism, doctors’ authority was questioned (After the World War Ⅱ, inhumane human body experiments by deceiving or inducing experiment subjects were carried out in America.), movements to protect patients’ rights were initiated, and plural cultural beliefs birthed in America. All these factors led people to concern and debate regarding bioethics. Facing various disagreements and disputes, many bioethicists have tried to build up a bioethics consensus with specific contents. Contrasted by mainline researches, American bioethics Engelhardt found a different approach. He proposed the Principle of Permission as a procedure bioethics consensus in light of the pluralistic context of many issues in bioethics and gave demonstration of a flexible solution to doctor-patient moral disputes. His research raised heated discussion among international bioethics field.In order to elaborate on the reasonableness of Engelhardt’s Principle of Permission, the author starts with studying the historical and theorial contexts of Engelhardt’s thoughts, namely post-modernity, moral plurality, limits of rationality, and the influence of classical liberalism. Influenced by these contexts, Engelhardt’s bioethics has strong post-modern characteristics. He acknowledges his book Foundations of Bioethics as a post-modern work. With such an approach, Engelhardt sees moral pluralism as unavoidable in America. In his view, since different moral communities have different moral presuppositions and premises, disputes among moral strangers are endless. His concern with these differences is one major founding point for his procedure principle. Different from the practice of moral projects in Enlightenment, which is to solve moral differences by establishing objective and universally effective moral values, Engelhardt sees the moral project in Enlightenment as impossible in a cross-cultural setting since objective and universally moral values only exist in specific moral communities. He believes that "all human morals are concerned with freedom, equality, prosperity, and safety. This might become a fact. Nevertheless, according to how we judge and combine these relationships, an obviously different moral form will be established." As we can see, Engelhardt has been influenced by Maclntyre and post-modernism. Advocating prepositions of post-modern plurality, heterogeneity, and equality, he believes that rationality fails to prove the superiority of a certain moral value. Based on this understanding, Engelhardt claims that the solution of moral differences can only resort to persons participating in the debates. Human beings are the source of moral authority. We can conclude from this that Engelhardt is a bioethicist with classical liberalism complex, although he himself denies such identification. Engelhardt asserts that he has never advocated the absolute value of personal choices. We have to resort to human beings as the source of moral authority due to the fact that we have ceased to receive grace from God and the collapse of moral project in Enlightenment. According to him, freedom is only a priori condition of bioethics. Since objective and universally effective common moral understanding cannot be established, procedure agreement might be the path for solving moral disputes.The elaboration of the context of Engelhardt’s thoughts and the analysis of his inclination provided the author a hermeneutical foundation for understanding Engelhardt’s thought of game playing between doctors’authority and patients’ autonomy. Engelhardt recognizes doctors’ paternalism authority in certain circumstances, for instance, towards "incompetent individuals"(which includes two types:one being those who have never had action capacity, such as infants, babies, and people born with severe mental disabilities; the other being those who used to have action capacity but failed to indicate their desired treatment before they lost the capacity, for example, those adults who had not written a will in advance and became a vegetable or fell into a coma), patients who are competent but indicated or hinted their entrusting of decision to the doctors. The question now is this, what shall we do when moral disputes happen between a doctor and a competent patient? He gives four solutions: enforcement, one of the two parties in disputes changes his standpoint, perfect rational demonstration, and agreement (also called permission, do not do unto others what you don’t want others do to you). As for the first approach, Engelhardt points out that because many people have noticed that knowledge is conditioned by its history and culture so any description of medical knowledge will be influenced by the history and culture of the communities that different scientists belong to. Therefore, we are not able to give a neutral, pure-descriptive illustration of any disease. Even though doctors could give what he thinks is the best and right medial strategy, the patient might not agree to it. Enforcement is impracticable because it is a typical ethical imperialism and a suppressive way without any reasoning. The second approach to doctor-patient conflicts is a bit complicated since situations in which doctor-patient conflicts are resolved because one of the disputing parties has given up his own stand do exist in reality. However, it is undeniable that it is unrealistic if we hope to solve all ethical disputes in this way, because history and reality have proved over and again that the major cultural traditions have not been integrated as one. Just as what Engelhardt says in the Introduction to his Foundations of Bioethics:in the20th century, some authoritarian political leaders tried to force one country into a single moral community. However, even after cruel suppression, plurality still exists as usual. So transiting from one moral community to another purely based on ones’ consciousness is a very occasional phenomenon. The third approach is to solve doctor-patient conflicts through satisfactory rational reasoning. After the Enlightenment Moral Project has lost its validity, its impossibility becomes a self-evident fact. In view of this, only the fourth approach is applicable, that is to say that "agreement (permission)" is the best approach possible for solving moral disagreements.According to Engelhardt, the fulfillment of Principle of Permission is based on three conditions:its participants are self-conscious, rational, moral, and free "human beings;" they should belong to a certain moral community;"freedom and informed consent" are at core in the fulfillment of the Principle. Based on the above analysis, the author goes further to compare the Principle of Permission and Principle of Benevolence, Principle of Permission and Principle of Justice, and to establish the priority of Principle of Permission through demonstration. This in some degree has overcome the limitation of Four Principles of bioethics (beneficial or benevolent, no harming, respecting independence, and just).Engelhardt’s Principle of Permission has caused heated debates in bioethics. The author sees the main value and significance of Principle of Permission as followings: first, Engelhardt has exceeded his Orthodox background and many communities and established a neutral moral framework, which is mutual respecting and equal negotiation. He set up the right moral proverb for moral strangers:do not do unto others what you don’t want others do to you. This helps peaceful cooperation between universal moral strangers; second, Engelhardt is opposed to using the western moral value as a universal ethical value. He respects the cultural traditions of each country and nation. For him, universal morality is a strong concept in the west and is seen as the only absolute right one by some Europeans due to their influence by the Enlightenment. Opposite from them, Engelhardt believes that moral values of moral strangers could be influenced by dialogue, communication, and persuasion. Everyone should be tolerant of careful and rational decisions made by moral strangers; thirdly, Engelhardt’s emphasis on Principle of Permission helps us to see the limitation of democratic systems by majority. Each individual should have the right of decision when it only involves major personal benefits and does not harm others or only cause harm in a trivial way. Of course, Principle of Permission is not perfect and cannot solve all bioethics problems. This does not hurt its values. The author believes that Engelhardt has give us a very satisfactory demonstration regarding moral disputes among moral strangers, which is the setting the limit of doctors’ paternalism and authority of national health care policies.What influence could such Principle of Permission with a classical liberalism tendency bring to China? The author believes that this Principle has significance for us whether we see modern Chinese society as a highly authoritarian or a secular society that’s walking towards plural values. First of all, with more and more overseas medical exchanges, medical cooperation will unavoidably face the dilemma of moral strangers. Possible moral disputes in such situations could be solved by using Principle of Permission. Secondly, since the reform of the medial system in1985, due to reasons like the scarcity of quality medical resources, rising of medical expenses, and market-oriented medical institutions, doctor-patient conflicts often take place and the doctor-patient relationship has deteriorated. It’s pressing to establish harmonious doctor-patient relationship. In this background, if we are careless in bringing advanced medical techniques and clinical application, doctor-patient conflict will be aroused. Therefore, in areas of organ transplantation, assisted reproduction, and human body experiments, we need to respect, inform, communicate and understand well. This way the equal exchange between doctors and patients will be enhanced and trust between doctors and patients re-established.更多还原